State of Wisconsin Department of Health Services

Release 24-02 August 22, 2024

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32.2 QMB

32.2.1 Introduction

To be eligible for Qualified Medicare Beneficiary (QMB) benefits, the person must:

1. Meet non-financial Medicaid requirements
2. Be entitled to Medicare Part A or Part B-ID (as defined in Section 32.2.2 Entitled to Medicare).

The following Medicaid members are categorically eligible for QMBQualified Medicare Beneficiary:

• People who are receiving or are eligible to receive SSISupplemental Security Income. A program based on financial need operated by the Social Security Administration that provides monthly income to low income people who are age 65 or older, blind, or disabled. Medicaid
• People who are eligible for Special Status Medicaid as a 503 or Disabled Adult Child (DAC)

 

Example 1

Kate receives Social Security Disabled Child DAC benefits from Social Security. Due to other unearned income, Kate is not eligible for Special Status Medicaid as a DAC. Therefore, she is not categorically eligible for QMB even though she receives a DAC payment.

32.2.2 Entitled to Medicare

A person is "entitled" to Medicare Part A or Part B-ID if they meet one of the following conditions:

1. They do not have to pay a premium for Medicare Part A and are enrolled in Medicare Part A as of the QMB determination.

   Example 1

   Mrs. Smith applies for QMB benefits August 15. She has a Medicare card with a Part A begin date of June 1. Since Medicare will pay for Part A services as of June 1, she is "entitled" to Part A at the time of the QMB determination.

2. They must pay a monthly premium to receive Medicare Part A and meet one of the following conditions:
   1. They are a Medicaid member and have been enrolled in Medicare sometime in the past. In this case, the state will attempt to enroll them in Medicare Part A. QMB eligibility cannot begin prior to the Part A begin date.

      Example 2

      Eleanor's Part A lapsed because she did not work enough quarters for free enrollment, and she could no longer afford the premiums. When she becomes eligible for Medicaid, the state will begin paying her Medicare premiums.

   2. They are a Medicaid member or a QMB or Specified Low-Income Medicare Beneficiary (SLMB) applicant and have never been enrolled in Medicare Part A. In this case, they must apply at the local Social Security Administration (SSA) office for Part A Medicare eligibility. The SSA office will add comments to the "Remarks" section of the application and provide a screen shot that can serve as proof of conditional Part A enrollment provided the applicant is found eligible for QMB or SLMB. SSA will provide the Part A begin date. QMB or SLMB eligibility cannot begin prior to the Part A begin date. The earliest QMB can begin is the month after the month of application.

      Note:

      For purposes of QMB or SLMB, a person can request conditional enrollment in Medicare Part A at their local SSA office at any time. They do not have to wait for the general enrollment period.

       

      Example 3

      Pearl was never enrolled in the federal Medicare system. She applies for QMB. Before she can become QMB eligible she must obtain proof of conditional eligibility for Medicare Part A. She goes to the SSA office and is conditionally determined eligible for Part A effective June 1. She applies for QMB at the IMincome maintenance Agency on May 1. She becomes QMB eligible as of June 1.

3. They are enrolled in Medicare Part B Immunosuppressive Drug (Part B-ID).

32.2.3 Income Limit

The QMB income limit is 100% of the FPLFederal Poverty Level (see Section 39.5 FPL Table).

The method of counting income is based on the SSI method, not on the spousal impoverishment"Spousal Impoverishment Protection" refers to special financial provisions in Medicaid law regarding income and assets that affect certain married couples receiving or applying for nursing home or community waiver services. method (see Section 28.1 ADULT HOME AND COMMUNITY-BASED WAIVERS LONG-TERM CARE INTRODUCTION). Calculate QMB net income as follows:

$ Earned income (see Section 15.5 Earned Income)
- $65 and ½ earned income deduction (see Section 15.7.5 $65 and ½ Earned Income Deduction)
+ Unearned income (Social Security income, etc.) (see Section 15.4 Unearned Income)
- Special exempt income (see Section 15.7.2 Special Exempt Income)
- $20 standard deduction
= Net income used to determine QMB eligibility

When counting Social Security income, use the gross Social Security income. Gross Social Security income:

1. Of a self-payer = the Social Security check amount + Medicare premiums he or she has paid.
2. Of someone for whom the state is paying the premiums = the Social Security check amount.

The COLAcost-of-living adjustment. An increase in income to compensate for inflation. increase is disregarded for the current year until the month after the new federal poverty limits become effective.

Example 1

Al is a QMB member. He has income of 99% of the FPL. In January, a COLA increase of $15.00 increases Al's income above 100% of the FPL. The COLA increase is disregarded in any determination of Al's continuing QMB eligibility. On April 1, new QMB income limits are published. Redetermine Al's QMB eligibility in May using the new QMB income limits. At this redetermination, the January COLA increase is applied.

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The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.

Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.

Publication Number: P-10030